PFD · Response tracker

PFD Response Tracker

6,383 total 4,927 with responses identified 46 with 0 responses identified (past 2 years) 2 response window open 1,398 historic with 0 responses identified

Live tracking of every Prevention of Future Deaths report and the published responses identified for them under Regulation 28's 56-day deadline.

How response counts are interpreted — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so this tracker shows published responses we have identified there.

A report with at least one published response is counted as having a response identified, even if not every listed addressee has a separate published response. Reports with 0 responses identified are split by whether the response window is still open, within the last two years after that window, or older than two years. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.

Historic reports with 0 responses identified are more than two years old. Older reports may have received a response that was never made public. Treat these counts as a neutral data-coverage signal, not confirmed non-compliance.

33 reports include a non-response confirmed by the Chief Coroner. Show only confirmed →

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6,383 reports · Page 78 of 128

Date ↓	Deceased	Addressee(s)	Responses identified
29 Oct 2018	Karl Brunner The incident highlights a risk of future deaths where individuals swallow drugs during police stops, requiring a review …	ACPO Bedfordshire Police	1/2
29 Oct 2018	Rosario Cordero-Sanz Special police officers lacked essential equipment and training in mental health and missing person processes. Communication failures and …	Metropolitan Police Service	1/1
29 Oct 2018	Elizabeth Self Senior doctors lacked training in making proper X-ray requests. A communication breakdown caused a valid CT request to …	NHS England	1/1
29 Oct 2018	Thomas McAuley Disjointed communication and lack of universal access to medical records (DPMFs) across custody and prison healthcare services mean …	Serco Ltd Metropolitan Police Service Oxlea NHS Trust Thameside Prison	1/4
26 Oct 2018	Timothy Mason Failures in the Emergency Department led to incorrect diagnosis and treatment of sepsis, and the discharge of an …	Maidstone & Tunbridge Wells NHS … NHS England	1/2
25 Oct 2018	Andrea Franzosi Inadequate supervision of junior doctors on wards, specifically regarding patient discharges occurring without examination by a senior practitioner.	Gloucestershire NHS Trust	0/1
25 Oct 2018	David Sargeant The patient could not receive an ADHD diagnosis or treatment due to commissioning gaps, lack of specialist psychiatrists, …	Kernow Clinical Commissioning Group	1/1
25 Oct 2018	Eileen Cooke A frail elderly patient was prematurely discharged with unresolved medical issues, inadequate care planning, and without a 'best …	Mid Yorkshire Hospitals NHS Trust	1/1
24 Oct 2018	Jennifer Lacey Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient …	GPC NHS England	1/2
24 Oct 2018	Catherine Gibbon Significant safety failures included inadequate health pledge guidance, untrained staff for medical conditions, insufficient CCTV monitoring with a …	DW Fitness First UK Active	0/2
24 Oct 2018	Maximilien Kohler Misdiagnosis of ASD was linked to over-reliance on questionnaires and less experienced clinicians, compounded by a lack of …	CNWL NHS Trust Department of Health and Social … NHS England Royal College of Psychiatrist	2/4
23 Oct 2018	Allan Shepard Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient …	City Wide Alarms Sheffield City Council	0/2
23 Oct 2018	Nicola Lawrence A critical concern was that some prison staff lacked essential cardiopulmonary resuscitation (CPR) training, both initial and refresher, …	National Offender Management Service	1/1
23 Oct 2018	Kalma Ram-Henman Multiple clinical failings included an incomplete fluid chart, unadministered essential medications and fluids despite orders, missed ECG abnormalities, …	Brighton & Sussex University Hospitals …	1/1
19 Oct 2018	John Lee A clerical error severely delayed an urgent vascular appointment, changing an elective procedure to an emergency and contributing …	Medway NHS Trust	0/1
19 Oct 2018	Robert McLoughlin The jury identified errors and omissions in the care of an HMP Leeds inmate, which potentially contributed to …	HMPPS	0/1
19 Oct 2018	Trystan Bryant Stationary ambulance doors that cannot be locked pose a risk to police containment of individuals detained under the …	Dyfed-Powys Police National Police Chiefs’ Council	1/2
18 Oct 2018	Joseph Grantham Key concerns include significant delays in discharge paperwork and specialist letters, unclear care responsibility, missing patient notes, inadequate …	Department of Health and Social … Healthcare Safety Investigation Branch Manchester University NHS Foundation Trust	0/3
18 Oct 2018	Anne Roberts Inadequate training for bank staff on choking risks, poor dissemination of this information in patient records, and difficulties …	NHS Professionals Limited Prospect Park Hospital	0/2
16 Oct 2018	Jacqueline Oakes There is no system to alert other agencies when high-risk offenders are released after completing their full sentence, …	Home Office MOJ	1/2
16 Oct 2018	Jordan Sheils The council is delaying the implementation of anti-climbing mesh and CCTV cameras on a bridge, despite measures to …	Calderdale Metropolitan Borough Council	1/1
11 Oct 2018	Dean Barrell A seven-day delay in communicating a vulnerable prisoner's actual release date to HMP Lewes contributed to his suicide, …	Prison and Probation Service	1/1
11 Oct 2018	Thomas Lear A released prisoner was offered no accommodation support, and urgent suicide threats sent to his offender manager's mobile …	Staffordshire Police Ministry of Justice	0/2
10 Oct 2018	Robin McEwan Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family …	Harrogate & Rural District Clinical …	1/1
9 Oct 2018	Tom Cribley Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed …	Aintree University Hospital NHS Trust Care Quality Commission General Medical Council NHS England NHS South Sefton Clinical Commissioning … Nursing and Midwifery Council Public Health England	0/7
8 Oct 2018	Natasha Ednan-Laperouse Allergens were not adequately labelled on Pret-a-Manger packaging, and there was no coordinated system for monitoring customer allergic …	Department for the Environment, Food … Medicines and Healthcare products Regulatory … Pfizer Pret-a-Manger	2/4
4 Oct 2018	Michael Cooper Chronic underfunding of mental health services led to a critical lack of inpatient beds and excessive Care Coordinator …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	James McLaren Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of …	Chartered Institution of Waste Management Environmental Services Associations Health and Safety Executive Local Government Association	4/4
4 Oct 2018	Simon Graham Respite home had critical safety failures including lone working delaying emergency response, incorrect room labelling impeding access, and …	Birmingham Clinical Commissioning Group Future Care & Social Care … NHS England	2/3
4 Oct 2018	Michael Wheeler Inadequate mental health service funding led to a lack of psychiatrist review for a patient with severe paranoia …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Stephen Jackson Mental health services failed to provide essential post-discharge follow-up from the home treatment team despite an urgent GP …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	William Edge A suicidal patient was discharged without adequate follow-up from the Home Treatment Team, who could not revisit despite …	Birmingham Clinical Commissioning Group NHS England	2/2
4 Oct 2018	Bradley Morgan Mental health services suffered communication breakdowns and severe underfunding, resulting in excessive staff caseloads and a lack of …	Birmingham Clinical Commissioning Group NHS England	2/2
3 Oct 2018	Canon Frost Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …	East Coast Community Healthcare Team Head of the Roman Catholic … The Diocese of Westminster	1/3
3 Oct 2018	Charlotte Tripper A bus driver practice of avoiding eye contact with other drivers at junctions may increase the risk of …	National Express West Midlands	1/1
3 Oct 2018	Brian Frost Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits …	Diocese of Westminster the Roman Catholic Church of … Patrick Stead Hospital	0/3
3 Oct 2018	Theresa Button Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient …	Leeds Teaching Hospitals NHS Trust	1/1
2 Oct 2018	Joshua Edwards Ambulance response was delayed by public event road closures and unclear authority for crews to cross them. Event …	Leeds City Council	1/1
2 Oct 2018	Andrew Collins A severe lack of ambulance resources caused a critical three-hour delay in dispatching a vehicle to a rapidly …	Welsh Ambulance Service NHS Trust	1/1
1 Oct 2018	Hayley Gascoigne The Hull Combined Court Centre lacked a defibrillator, despite expert opinion that all public buildings should be equipped …	HM Courts and Tribunals Services The Hull Combined Court Centre, …	1/2
1 Oct 2018	Michael Hopkins Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent …	Bradford Teaching Hospitals NHS Trust	1/1
1 Oct 2018	Joan Blaber Significant failures in hospital housekeeping included non-compliance with COSHH regulations, inadequate staff training, confusion of roles, poor communication …	Brighton and Sussex University NHS …	1/1
28 Sep 2018	Donald Berry The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail …	Department of Health and Social … Health and Safety Executive Kendal Calling The Secretary of State for …	3/4
27 Sep 2018	Julia MacPherson Failure to review a patient despite severe side effects and family concerns, inadequate mental capacity assessments, poor record-keeping …	Care Quality Commission Department for Health Oxleas NHS Trust	2/3
27 Sep 2018	Sheila Hadfield A national shortage of suitable care beds for individuals with complex mental health needs resulted in placements in …	Department of Health and Social …	1/1
27 Sep 2018	Mary Ryder Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and …	Department of Health and Social …	1/1
26 Sep 2018	John Waite Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood …	British Renal Society, EBS Ltd. Intensive Care Society The Renal Association Salford Royal NHS Foundation Trust Department of Health and Social …	2/5
26 Sep 2018	Angela Jackson A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names …	Liverpool Heart and Chest Hospital … Lancashire Teaching Hospitals NHS Foundation … Manchester University NHS Foundation Trust Department of Health and Social …	2/4
26 Sep 2018	Bridget Marie Connell-Graham The lack of a clear national definition for 'cervical trauma' leads to inconsistent approaches in investigating prior history …	Department for Health	1/1
25 Sep 2018	Caitlin Huddleston and Skye Mitchell Inexperienced young drivers carrying multiple passengers face increased distraction and risk, highlighting the need for a Graduated Driving …	Department for Transport	2/1